HHS Public Access Author manuscript Author Manuscript
Urology. Author manuscript; available in PMC 2017 August 01. Published in final edited form as: Urology. 2017 August ; 106: 26–31. doi:10.1016/j.urology.2017.03.058.
Overactive bladder is strongly associated with frailty in older individuals Anne M. Suskind, MD, MS1, Kathryn Quanstrom1, Shoujun Zhao, PhD, Mark Bridge1, Louise C. Walter, MD2,3, John Neuhaus, PhD4, and Emily Finlayson, MD, MS5
Author Manuscript
1University
of California, San Francisco Department of Urology
2University
of California, San Francisco, Division of Geriatrics
3Veterans
Affairs Medical Center, San Francisco, California, Division of Geriatrics
4University
of California, San Francisco, Department of Epidemiology and Biostatistics
5University
of California, San Francisco, Department of Surgery
Abstract Objectives—To understand the relationship between age, frailty and overactive bladder (OAB).
Author Manuscript
Methods—This is a prospective study of individuals age ≥65 presenting to an academic urology practice between December 2015 and July 2016. All patients had a Timed Up and Go Test (TUGT), a parsimonious measure of frailty, on intake and were thereby categorized as fast (≤10 sec), intermediate (11-14 sec) and slow (≥15 sec). The TUGT and other clinical data were abstracted from the electronic medical record (EMR) using direct queries. Logistic regression was used to examine the relationship between frailty and the diagnosis of OAB, adjusting for age, gender and race. Results—Our cohort included 201 and 1162 individuals with and without OAB, respectively. Individuals with OAB had slower TUGTs (13.7 ± 7.9 sec) than their non-OAB counterparts (10.9 ± 5.2 sec), p0.05 for each age group).
Author Manuscript
Conclusions—Patients with OAB are statistically significantly frailer than individuals seeking care for other non-oncologic urologic diagnoses. Frailty, when adjusted for age, race and gender, is a statistically significant predictor of OAB. Furthermore, frailty should be considered when caring for older patients with OAB and OAB should be assessed when caring for frail older patients. Keywords OAB; timed up and go test; TUGT; geriatric; lower urinary tract; elderly
Corresponding Author: Anne M Suskind, MD, MS, 400 Parnassus Ave, Box 0738, San Francisco, CA 94143, 415-476-1611, Fax: 415-476-8849, [email protected].
Suskind et al.
Page 2
Author Manuscript
Introduction Overactive bladder affects approximately one third of men and women over the age of 65.1,2 Defined as urgency (with or without leakage of urine) and usually associated with increased frequency and nocturia,3 overactive bladder is associated with increased mortality,4 morbidity,5 marked decrease in health-related quality of life6 and significant economic burdens totaling over $65 billion per year.7
Author Manuscript
Current paradigms suggest that the pathophysiology associated with aging is responsible for the development of symptoms of overactive bladder. These changes include, but are not limited to, decreased bladder capacity, decreased bladder sensation, impaired detrusor contractile function during voiding and increased residual volume8,9 However, increasing age is also associated with increasing frailty, defined as a multifactorial syndrome manifested by a reduction in physiologic reserve and in the ability to resist stressors.10 This brings to question whether it is really age, or rather, frailty that impacts the presence of overactive bladder. Using data from the University of California, San Francisco Geriatric Urology Database (UCSF-GUD) on all individuals ages 65 and older visiting our academic non-oncologic urology clinical practice, we evaluated the association between frailty, measured by the Timed Up and Go Test (TUGT), and a diagnosis of overactive bladder. Findings from this study will help to unravel the complicated relationship between age, frailty and overactive bladder to help further our understanding of this common and problematic condition in the older population and potentially lay the groundwork for a new conceptual model of overactive bladder.
Author Manuscript
Materials and Methods Patients and Database We used data from the UCSF-GUD from December 2015 to July 2016. This Institutional Review Board (IRB) approved database prospectively collects data on all patients age 65 and older presenting to our adult non-oncologic urology clinical practice. Data are regularly extracted directly from the electronic medical record (EPIC) using extract, transform and load (ETL) routines via the clinical data reporting database (Clarity) and datamart (Cogito).
Author Manuscript
Specifically, data extraction occurred in 6 steps. The first step started with a query that identified patients with a completed appointment in a particular clinic with a relevant list of providers. The second step took the set of patients identified in the first step and calculated their age in years (to ensure that they were 65 years or older at the time of the visit) and obtained relevant demographic information. Third, we ran queries for all TUGT values entered into EPIC in the specified appointment date range and crosschecked this output with that from step 2 to ensure that there were no missed values. Fourth, we abstracted operating room data and current procedural terminology (CPT) codes that were scheduled with the relevant list of providers during the time range of the study. Procedures annotated as “cancelled” were eliminated and the remainder of the procedures were connected with the patients identified in step 2. Fifth, we abstracted all problem list data from the patients
Urology. Author manuscript; available in PMC 2017 August 01.
Suskind et al.
Page 3
Author Manuscript
identified in step 2 including International Statistical Classification of Diseases (ICD-9 and 10) codes, diagnosis name entered into the chart, diagnosis group, noted date, problem status and resolved date where appropriate. Finally, we abstracted medication data for patients identified in stage 2 including the pharmacologic and therapeutic medication classes. Outcome
Author Manuscript
We identified patients in the UCSF-GUD with a diagnosis of overactive bladder using the followingICD-9 and 10 codes: 596.51 hypertonicity of bladder; 788.63 urgency of urination; 788.41 urinary frequency; 788.31 urge incontinence; 788.33 mixed incontinence. We originally identified 226 individuals with overactive bladder based on coding alone. We then reviewed each of the charts on individuals with an overactive bladder diagnosis and found that 25 of these charts represented patients who had other types of lower urinary tract symptoms, for an overall accuracy of 89%. We excluded these 25 patients with other diagnoses from our analyses so that 100% of our cohort had a diagnosis of overactive bladder. Seventy-four percent of individuals had their diagnosis of overactive bladder on the same date as their TUGT. Patients were excluded from the cohort if they declined the TUGT, if no TUGT was recorded, or if they were in a wheelchair, precluding them from being able to perform the TUGT. Covariates
Author Manuscript Author Manuscript
We used the TUGT as our measure of frailty, which we administer to all patients age 65 and older upon intake to our clinical practice at each office visit upon their approval. In order to complete this test, individuals are instructed to stand up from a chair, walk 10 feet at a normal pace (they can use a walker, cane, or other walking device if needed), walk back to the chair and sit down again. This task requires assimilation of several elements including understanding and following directions, transfer from a seated to a standing position (and vice versa), walking speed, strength and balance. Slower walking speed has demonstrated sensitivity and specificity as a measure of frailty,11 and has been associated with increased postoperative complications across surgical subspecialties. The TUGT can be used to categorize individuals as “fast” (≤10 seconds), “intermediate” (11-14 seconds) and “slow” (≥15 seconds), with corresponding implications for frailty being “not frail”, “intermediately frail” and “frail”, respectively.12 Individuals in wheelchairs are not able to complete this test, and are noted as such in the database. If an individual had more than one office visit within the study period, only their first recorded TUGT was used in the analyses. The TUGT values in addition to demographic and clinical information pertaining to age (age groups: 65-70, 71-75, 75-80, 81+), sex, race (White, Black, Asian, other), number of medications (medication groups: 1-5, 6-10, 11-15, 16-20, >20), the presence of urinary incontinence [based on ICD-9 codes 788.31 (urge incontinence) and 788.32 (stress incontinence male or female)] and number of office visits were abstracted from the database. Statistical Analysis Summary characteristics of patients with and without a diagnosis of overactive bladder were presented as averages with standard deviations or as numbers and percentages and were compared using t-tests with two-sided p values
Urology. Author manuscript; available in PMC 2017 August 01. Published in final edited form as: Urology. 2017 August ; 106: 26–31. doi:10.1016/j.urology.2017.03.058.
Overactive bladder is strongly associated with frailty in older individuals Anne M. Suskind, MD, MS1, Kathryn Quanstrom1, Shoujun Zhao, PhD, Mark Bridge1, Louise C. Walter, MD2,3, John Neuhaus, PhD4, and Emily Finlayson, MD, MS5
Author Manuscript
1University
of California, San Francisco Department of Urology
2University
of California, San Francisco, Division of Geriatrics
3Veterans
Affairs Medical Center, San Francisco, California, Division of Geriatrics
4University
of California, San Francisco, Department of Epidemiology and Biostatistics
5University
of California, San Francisco, Department of Surgery
Abstract Objectives—To understand the relationship between age, frailty and overactive bladder (OAB).
Author Manuscript
Methods—This is a prospective study of individuals age ≥65 presenting to an academic urology practice between December 2015 and July 2016. All patients had a Timed Up and Go Test (TUGT), a parsimonious measure of frailty, on intake and were thereby categorized as fast (≤10 sec), intermediate (11-14 sec) and slow (≥15 sec). The TUGT and other clinical data were abstracted from the electronic medical record (EMR) using direct queries. Logistic regression was used to examine the relationship between frailty and the diagnosis of OAB, adjusting for age, gender and race. Results—Our cohort included 201 and 1162 individuals with and without OAB, respectively. Individuals with OAB had slower TUGTs (13.7 ± 7.9 sec) than their non-OAB counterparts (10.9 ± 5.2 sec), p0.05 for each age group).
Author Manuscript
Conclusions—Patients with OAB are statistically significantly frailer than individuals seeking care for other non-oncologic urologic diagnoses. Frailty, when adjusted for age, race and gender, is a statistically significant predictor of OAB. Furthermore, frailty should be considered when caring for older patients with OAB and OAB should be assessed when caring for frail older patients. Keywords OAB; timed up and go test; TUGT; geriatric; lower urinary tract; elderly
Corresponding Author: Anne M Suskind, MD, MS, 400 Parnassus Ave, Box 0738, San Francisco, CA 94143, 415-476-1611, Fax: 415-476-8849, [email protected].
Suskind et al.
Page 2
Author Manuscript
Introduction Overactive bladder affects approximately one third of men and women over the age of 65.1,2 Defined as urgency (with or without leakage of urine) and usually associated with increased frequency and nocturia,3 overactive bladder is associated with increased mortality,4 morbidity,5 marked decrease in health-related quality of life6 and significant economic burdens totaling over $65 billion per year.7
Author Manuscript
Current paradigms suggest that the pathophysiology associated with aging is responsible for the development of symptoms of overactive bladder. These changes include, but are not limited to, decreased bladder capacity, decreased bladder sensation, impaired detrusor contractile function during voiding and increased residual volume8,9 However, increasing age is also associated with increasing frailty, defined as a multifactorial syndrome manifested by a reduction in physiologic reserve and in the ability to resist stressors.10 This brings to question whether it is really age, or rather, frailty that impacts the presence of overactive bladder. Using data from the University of California, San Francisco Geriatric Urology Database (UCSF-GUD) on all individuals ages 65 and older visiting our academic non-oncologic urology clinical practice, we evaluated the association between frailty, measured by the Timed Up and Go Test (TUGT), and a diagnosis of overactive bladder. Findings from this study will help to unravel the complicated relationship between age, frailty and overactive bladder to help further our understanding of this common and problematic condition in the older population and potentially lay the groundwork for a new conceptual model of overactive bladder.
Author Manuscript
Materials and Methods Patients and Database We used data from the UCSF-GUD from December 2015 to July 2016. This Institutional Review Board (IRB) approved database prospectively collects data on all patients age 65 and older presenting to our adult non-oncologic urology clinical practice. Data are regularly extracted directly from the electronic medical record (EPIC) using extract, transform and load (ETL) routines via the clinical data reporting database (Clarity) and datamart (Cogito).
Author Manuscript
Specifically, data extraction occurred in 6 steps. The first step started with a query that identified patients with a completed appointment in a particular clinic with a relevant list of providers. The second step took the set of patients identified in the first step and calculated their age in years (to ensure that they were 65 years or older at the time of the visit) and obtained relevant demographic information. Third, we ran queries for all TUGT values entered into EPIC in the specified appointment date range and crosschecked this output with that from step 2 to ensure that there were no missed values. Fourth, we abstracted operating room data and current procedural terminology (CPT) codes that were scheduled with the relevant list of providers during the time range of the study. Procedures annotated as “cancelled” were eliminated and the remainder of the procedures were connected with the patients identified in step 2. Fifth, we abstracted all problem list data from the patients
Urology. Author manuscript; available in PMC 2017 August 01.
Suskind et al.
Page 3
Author Manuscript
identified in step 2 including International Statistical Classification of Diseases (ICD-9 and 10) codes, diagnosis name entered into the chart, diagnosis group, noted date, problem status and resolved date where appropriate. Finally, we abstracted medication data for patients identified in stage 2 including the pharmacologic and therapeutic medication classes. Outcome
Author Manuscript
We identified patients in the UCSF-GUD with a diagnosis of overactive bladder using the followingICD-9 and 10 codes: 596.51 hypertonicity of bladder; 788.63 urgency of urination; 788.41 urinary frequency; 788.31 urge incontinence; 788.33 mixed incontinence. We originally identified 226 individuals with overactive bladder based on coding alone. We then reviewed each of the charts on individuals with an overactive bladder diagnosis and found that 25 of these charts represented patients who had other types of lower urinary tract symptoms, for an overall accuracy of 89%. We excluded these 25 patients with other diagnoses from our analyses so that 100% of our cohort had a diagnosis of overactive bladder. Seventy-four percent of individuals had their diagnosis of overactive bladder on the same date as their TUGT. Patients were excluded from the cohort if they declined the TUGT, if no TUGT was recorded, or if they were in a wheelchair, precluding them from being able to perform the TUGT. Covariates
Author Manuscript Author Manuscript
We used the TUGT as our measure of frailty, which we administer to all patients age 65 and older upon intake to our clinical practice at each office visit upon their approval. In order to complete this test, individuals are instructed to stand up from a chair, walk 10 feet at a normal pace (they can use a walker, cane, or other walking device if needed), walk back to the chair and sit down again. This task requires assimilation of several elements including understanding and following directions, transfer from a seated to a standing position (and vice versa), walking speed, strength and balance. Slower walking speed has demonstrated sensitivity and specificity as a measure of frailty,11 and has been associated with increased postoperative complications across surgical subspecialties. The TUGT can be used to categorize individuals as “fast” (≤10 seconds), “intermediate” (11-14 seconds) and “slow” (≥15 seconds), with corresponding implications for frailty being “not frail”, “intermediately frail” and “frail”, respectively.12 Individuals in wheelchairs are not able to complete this test, and are noted as such in the database. If an individual had more than one office visit within the study period, only their first recorded TUGT was used in the analyses. The TUGT values in addition to demographic and clinical information pertaining to age (age groups: 65-70, 71-75, 75-80, 81+), sex, race (White, Black, Asian, other), number of medications (medication groups: 1-5, 6-10, 11-15, 16-20, >20), the presence of urinary incontinence [based on ICD-9 codes 788.31 (urge incontinence) and 788.32 (stress incontinence male or female)] and number of office visits were abstracted from the database. Statistical Analysis Summary characteristics of patients with and without a diagnosis of overactive bladder were presented as averages with standard deviations or as numbers and percentages and were compared using t-tests with two-sided p values
